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Outcomes After Carotid Endarterectomy: Is There a High-Risk Population? A National Surgical Quality Improvement Program Report

Jeanwan Kang, Thomas K. Chung, Vikram Paruchuri, Robert T. Lancaster, Matthew M. Hutter, Glenn M. LaMuraglia, Mark F. Conrad, Richard P. Cambria.
Massachusetts General Hospital, Boston, Mass.

OBJECTIVES: Carotid endarterectomy (CEA) is the standard treatment of carotid stenosis, yet carotid angioplasty and stenting (CAS) have been proposed as appropriate therapy for patients deemed “high-risk” for CEA. We studied the validity of this concept by examining 30-day adjudicated outcomes in a contemporary series of CEAs.

METHODS: Patients undergoing isolated CEA in private sector hospitals between 1/1/2005 and 12/31/2006 were identified using the prospectively gathered National Surgical Quality Improvement Program database. Thirty-day stroke and death rates were the primary study end points. Demographic, preoperative and intraoperative variables were examined using multivariate models to identify variables associated with the study end points. “High-risk” patients included those with active cardiac disease, severe chronic obstructive pulmonary disease, or octogenarian status as defined in the SAPPHIRE study (comparative CEA vs. CAS).

RESULTS: A total of 3949 CEAs (59% male; 30% “high-risk” [19% age≥80]; 43% with previous neurologic event) were carried out. Thirty-day stroke rate was 1.6%, death rate 0.7%, and combined stroke/death rate 2.2%. Multivariate analysis showed intraoperative transfusion (OR=5.95 [1.71-20.66]; p=0.005), prior major stroke (OR=5.34 [2.96-9.64]; p<0.001), lower height (surrogate for small artery size; OR=1.09 [1.02-1.16]; p=0.010), and increased anesthesia time (OR=1.02 [1.00-1.03]; p=0.008) to be predictive of stroke. Active rest pain/gangrene (OR=12.46 [3.41-45.57]; p<0.001) and poor functional status (OR=7.34 [3.07-17.53]; p<0.001) were predictive of death. Variables included in “high-risk,” either combined or individually, did not increase risk of stroke or death on multivariate analysis.

CONCLUSIONS: CEA is associated with favorable 30-day outcomes across a spectrum of patient comorbidity features including octogenarian status. These data indicate that anatomic and technical features are important predictors of stroke, whereas advanced systemic illness is an important predictor of death for patients undergoing CEA. Furthermore, our data refute the concept that CAS is preferred for patients deemed “high-risk” by virtue of systemic comorbidities.

AUTHOR DISCLOSURES: J. Kang, None; T.K. Chung, None; V. Paruchuri, None; R.T. Lancaster, None; M.M. Hutter, None; G.M. LaMuraglia, None; M.F. Conrad, None; R.P. Cambria, None.